Physicians can reduce their documentation time by working with a scribe. However, what scribes document and how their actions affect existing documentation workflows is unclear. This study leverages electronic health record (EHR) audit logs to observe how scribes affected the documentation workflows of seven physicians and their staff across 13,000 outpatient ophthalmology visits. In addition to editing progress notes, scribes routinely edited exam findings and diagnoses. Scribes with clinical training also edited items such as vital signs that a scribe without clinical training did not. Every physician edited patient records later in the day when working with a scribe and those who deferred their editing the most had some of the largest reductions in EHR time. These results suggest that what scribes document, how physicians work with scribes, and scribe impact on documentation time are all highly variable, highlighting the need for evidence-based best practices.
Keywords: Documentation; Electronic Health Records.